Professional Boxing and Combat Sports Regulations 2008 S.R. No. 82/2008

Form 4

Regulation 8(1)(a) Sch. Form 4 FORM 4 substituted by S.R. No. Professional Boxing and Combat Sports Act 1985 154/2013 reg. 11. APPLICATION FOR REGISTRATION AS A PROFESSIONAL CONTESTANT Applicant details: Name: Competition Name (if different from your real name): Address: Telephone: Email: Date of birth:

Current trainer's name: Trainer's Telephone:

1. Have you ever been registered or disciplined as a professional contestant in any other state or territory of Australia or overseas? *YES/NO If Yes, please give details: 2. Have you competed as an amateur? *YES/NO 3. Please provide details of your last 5 boxing and combat sport contests (amateur, professional or both): If none please state accordingly:

Details of injuries or Date Place Opponent Result suspension Professional Boxing and Combat Sports Regulations 2008 S.R. No. 82/2008

Form 4

4. *I enclose evidence of my age (such as a certified copy of my driver's licence or other government-issued photographic identification)/I will present evidence of my age (such as my driver's licence or other government-issued photographic identification) to the Combat Sports Unit in person. 5. I enclose a Certificate of Fitness provided by a registered medical practitioner (Form 5). [Note: the medical examination must be completed within 14 days before the date of this application]. 6. I also enclose a completed Blood Testing form (Form 7). 7. I consent to the collection of medical information relating to me on the understanding that it is collected for the purposes of protecting my health and safety and that of other contestants, and that this information will be kept private in accordance with the Health Records Act 2001, except where disclosure to other parties is provided for in the Act and the Regulations. *YES/NO 8. I consent to the collection of information relating to injuries sustained by me at professional contests on the understanding that it is collected for the purposes of informing research into professional boxing and combat sports injuries to promote the health and safety of professional contestants. I accept that this information will be retained by the state and national governments and may be made available to academic researchers under strict guidelines, but that I will not be identifiable by name. *YES/NO 9. I understand that boxing and combat sports are hazardous activities that may lead to serious injury. In particular, successive blows to the head may lead to movement of the brain within the skull of a contestant, rupturing veins, and in rare cases, arteries. The resulting bleeding may lead to the formation of blood clots, causing pressure inside the skull, restricting the supply of oxygen to the brain and causing serious damage to the brain and even death. In seeking registration as a professional contestant I knowingly accept this risk. Signature: Date: Professional Boxing and Combat Sports Regulations 2008 S.R. No. 82/2008

Form 4

Registration fee: $100 Payable by: Cheque Money Order Credit card/Debit card NOTE: Cash payment is not accepted. *Cross out whichever is not applicable. ______